Tuesday, November 23, 2010

Polypharmacy

I was working at a rural health clinic seeing patients one afternoon when I picked up an intake questionnaire on a new patient waiting to see me in the exam room, I was outside of.  It stated that he was an African-American male, 48 years old, slightly obese, and 6’4” tall.  He was coming into the clinic to be seen as a new patient due to his hypertension and diabetes. 
I walked in and introduced myself.  “How can I help you?”
“I’m here because I’ve tried 3 other medical practices in the past 6 months and all they have done is add on medication on top of medication and none of them have made any difference to me.  So I’m hoping you’re different.”
“Well, I’ll certainly try.  What medications have you been put on for your hypertension and type 2 diabetes I see listed here on your intake questionnaire?”
With that, the patient lifted up a grocery sack and spilled all of them out on the exam table.  My eyes popped open.  There were at least 20 medicine bottles there, and upon inspection they had several different physicians names on them who had clinics locally. 
“Do you know which medication to take for your blood pressure and which ones for your diabetes?”
“No, that’s part of the problem, no one really explained anything to me.”
“I see.”  I took a look at his blood pressure reading the medical assistant got for me.  Whoa, I said to myself, it was 280/170.” 
“Are you having any symptoms like headache, dizziness, blurriness, numbness, blood in your urine, anything?”
“Nope, I feel my usual.”
“I see.  When was the last time you took any of these medications?”
“About a week ago, I don’t like taking meds I don’t understand the reason for.”
“Well, why we’re figuring out all your medications, I need you to take some of this long acting cardizem you have here, as well as 2 of these 50 mg tabs of tenorectic.  Both of these blood pressure meds will help bring your pressure down.  I also need you to take one of these metformin and glyburide tablets.”
“Do you have any health insurance?”
“No, that’s probably why the other medical clinics just gave me all of these drugs and then didn’t schedule a follow-up appointment for me.”
“Okay, well I’ll work with you, but first I need you to lay down here on the exam table quietly for about 30 minutes until the meds you just took begins to work and then I’m going to have to get some blood drawn on you, a urinalysis and an EKG.  But that will wait until your pressure is down.”
While he was laying quietly in the exam room, I went ahead and did my physical exam, listening to his lungs, heart, doing the abdominal exam, making sure I didn’t hear or feel a possible abdominal aneurysm.  I felt for his distal pulses in his feet and wrists, also listening in on his carotid arteries for any bruits.  Nothing was abnormal so far on his physical exam. 
“Would the patient be able to dodge the bullet after all?” I thought to myself.

Working in a rural health clinic on a patient who didn’t have any health insurance and worked as a day laborer precluded my calling an ambulance on him to have him transported south to Galveston (90 minutes by car) to be admitted to the in-patient unit at the public hospital for a medical work-up.  Instead I would have to do the best I could at the clinic.  
So I would have to check his kidney function due to the hypertension he had.  The increased blood pressure had the potential for causing renal insufficiency or failure.  He would also need to have an electrocardiogram done to check his heart function for any heart failure, or previous unsuspected history of heart disease.  Blood work would need to be done to check for his sodium levels and potassium levels.  His urine would need to be checked for any protein, infection or possible blood.   

I went back into the patient’s exam room where he was laying quietly in a darkened room.  I re-checked his blood pressure, thankfully it was coming down.  It was now 240/135.  I had the medical assistant come in and draw the necessary blood work on him.  I also had him use the restroom facilities so that we could acquire a urine sample which the medical assistant immediately did a urine dipstick on. 

His dipstick showed 1+ protein, 2+ glucose, no ketones, no blood, no white blood cells.  The medical assistant took the EKG machine into the patient who by this time was laying back down on the exam table.  About 10 minutes later the medical assistant came out and gave me the EKG reading. 
I looked at the EKG, no Q waves, no elevated ST waves, with normal sinus rhythm.  In addition, there wasn’t any signs of cardiac disease.  I thought to myself, “maybe this patient is going to ‘miss the bullet’.  I certainly hope so, he’s tried to be seen by physicians in the recent past regarding his elevated blood pressure readings, but no one has ever followed up with him.”

I continued to have the patient lay quietly in the darkened exam room resting for 2 hours while the medical assistant went in every 30 minutes to get his blood pressure readings.  Finally, 2 hours after he took his blood pressure meds in my presence, his reading was 150/85.  With this reading I let him go home and made him an appointment to come back in the morning to see me again.  I advised him to re-take the cardizem, tenorectic again in the am.  I kept the remaining medications he had come in with, all 18 bottles of them. 

I walked back into my office and went through the various medication bottles.  The patient could almost stock a pharmacy with all of the medicines he had.  There were 5 different medications for his diabetes, 8 different blood pressure medications, several of which were the same medications, just prescribed with different strengths.  No wonder the patient couldn’t keep any of his medications straight.

The following morning the patient returned for his 9 am appointment.  I had scheduled him for a full hour.  The medical assistant took his blood pressure reading and lo and behold it was 135/80.  I was estastic!

I knocked on the exam room door and then walked in.  I gave the patient a ‘high five’ with my hand for his wonderful blood pressure reading.  That morning I had also received his blood work back and his renal function showed a BUN of 23, and a creatinine of 1.1 (normal).  His sodium and potassium were fine, his glucose was understandably high at 320. 

I spent the next hour going over his three blood pressure medications I wanted him to stay on, how frequently per day to take them and how they would complement each other.  I then explained to him the diet he needed to adhere to, the amount of calories he could eat per day, that he needed to begin an exercise program of walking every day, as well as the two diabetic medications he needed to take, one of which was metformin and the other was glyburide.  I gave him a pill box so he could sort out the 5 medications he would need to take every day, with only having to remember to take his meds twice a day.   

The medical assistant came in and showed him how to do his finger sticks for his daily blood glucose levels.  We sent him home with a blood glucose machine and plenty of chemsticks to use with it.  (We had recently done a community health screening clinic sponsored by some of the local drug reps who had paid for the medical equipment we would need to use.  Hence we gave him one of these leftover glucose monitoring machines.)  Then we sent the patient home with a food chart, a blood glucose chart, as well as a blood pressure chart.  The patient was advised where he could go and get his blood pressures taken without having to own his own blood pressure machine.

By the time the patient left the clinic he had all sorts of patient informational material to read at home from the American Diabetic Association, and the American Heart Association.  It was in an easy to read format.  I had him come back in and see me in a week.

Patients can be non-compliant with their medical regimens due to many reasons.  One of those reasons is the patient’s lack of understanding about their disease, the medications and/or lifestyle changes they need to take to control their disease.  Patients need  to be educated on a level they can understand (usually on a 6th to 8th grade level). 

Many chronic diseases do not have any symptoms initially, so patients think that they don’t need to do anything about it.  Unfortunately, with some patients by the time they have symptoms it ends up being too late.  Patients end up having end stage organ disease or organ failure.  So we as clinicians have to be vigilant with our teaching of our patients, continually reviewing the importance of taking their medications, continue their lifestyle changes and stay with their medical regimen long-term.  We have to continue to remind our patients of the long-term complications they are facing due to their chronic disease, otherwise we are doing them a disservice.        

During the week at work, the medical assistant and I both made bets as to whether the patient would adhere to all of the teaching I had given to him.  The medical assistant didn’t think he would be able to stick to it, I hoped he could. 

The week went by before I knew it.  I walked out of one of the exam rooms after seeing a patient and the medical assistant walked up to me with a thin chart in his hands.  He slapped it into my hands as he said, “you won!”

“I won what?” 
“Take a look at the name on the chart.  You won, his blood pressure is normal and he has all of his readings for his glucose, blood pressure readings and what he’s eaten with him.  You won!”

"Really, you’re kidding?”
“Nope, he’s even got a big grin on his face, he’s so pleased with himself.”
“Wow, I’m amazed!”

I walked into the patient’s exam room and sure enough, I had never seen such a wide grin on a patient’s face as I had with him.  I gave the patient a double ‘high five’ with my hands for what he had been able to accomplish in the past week.

I went over his charts, his blood pressure readings on three medications were finally staying in the normal range.  His food diary showed that he was really trying to switch over from processed foods to more chicken with fruits and vegetables.  He had stopped eating (at least for the past week) all of his snack foods (potato chips, cheese on crackers etc).  I could tell we still needed to work on his blood glucose levels, they were tending to stay in the range of 180-200, but that was so much better than the 320 from a week ago. 

“My girlfriend and I are walking every night for 30-45 minutes.  We decided that we like taking a stroll around the lake out where we live.”
“Wonderful, I replied.  You’re even getting your exercise in.  I’m very impressed with your progress.”
“I’m really trying doc, I am.  You’re the first person who has even worked with me to get me better, so I thought the least I could do in return is do as I was told.”
“Well, I’m very pleased with your progress.  I’m going to increase your metformin dose as well as your glyburide dose and this should bring your sugar levels down to near normal range.  Other than this, everything else will stay the same.  I’ll also get your cholesterol levels drawn when you come back and see me.  So come in on the morning before you see me and have them drawn by the medical assistant.  Have them drawn before you eat or drink anything.  I want you to come back in and see me in a month.  Keep up with your food diary, getting your blood pressure readings and doing your glucose readings twice a day.  Any questions?”
“No, I’m just happy that I finally found someone who’s willing to work with me.  Thanks, Doc.”
“You’re welcome.”

Seeing this patient in the rural health clinic reveals major problems with patient care,  they’re unable to get the medical care they need due to a lack of health insurance.                                                                                                                                                                                                                                                                                                                                  Sometimes inappropriate medical care is also due to physicians having a preconceived idea that the patient really doesn’t care about their health, so they don’t want to work with them.  There is also a problem with racial inequalities.  The medical literature is replete with journal publications documenting patients of another culture or ethnicity are not given the same medical care patients would receive if they were Caucasian.

Will the new health care reform bill address these problems?  I wonder.  It will address the lack of health care insurance, but it’s not going to do anything to change physician’s perception of patients they see, nor change the disparity in racial inequalities.  These are problems that go deeper than their lack of health insurance.   

 

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